Stroke Rounds: No Stroke Benefit With Ablation of Atrial Flutter

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Note that this retrospective analysis of administrative data suggests that catheter ablation of atrial flutter may be associated with small, but statistically significant decreases in subsequent healthcare utilization.

Note that the rate of stroke, arguably the most important "hard" clinical outcome, was not different between those who underwent catheter ablation and those who did not.

Catheter ablation of atrial flutter did not reduce the risk of stroke in an observational study.

But ablation was associated with significant reductions in inpatient hospitalizations (HR 0.88, 95% CI 0.84-0.92) and emergency department visits (HR 0.60, 95% CI 0.54-0.65), according to Gregory Marcus, MD, of the University of California San Francisco, and colleagues.

In addition, the risk of atrial fibrillation was lower after ablation (HR 0.89, 95% CI 0.81-0.97), but the risk of acute stroke was not (HR 1.09, 95% CI 0.81-1.45), the researchers reported online in PLOS ONE.

"The use of catheter ablation to treat a first episode of atrial flutter is currently a Class IIa recommendation; this procedure only receives a Class I recommendation after arrhythmia recurrence," they wrote. "Given the overall efficacy and safety of this procedure for the treatment of atrial flutter, our findings may support the use of catheter ablation as a first-line treatment for atrial flutter."

Ablation of atrial flutter has been shown to have a high rate of procedural success, to reduce the rate of flutter recurrence, symptoms, and morbidity, and to improve quality of life, but there is limited information about its effect on other clinical outcomes and healthcare utilization.

After adjustment for demographics and comorbidities, ablation was associated with decreases in hospitalizations and emergency department visits, but an increase in ambulatory surgery encounters (HR 1.63, 95% CI 1.54-1.73).

"The ambulatory surgery encounter during which a patient underwent atrial flutter ablation was counted as a post-ablation visit, likely accounting for the significantly increased hazard of an ambulatory surgery visit in the ablation group," the authors wrote. "Notably, atrial flutter ablation sufficiently reduced subsequent inpatient hospitalizations and emergency department visits to offset the increased encounters incurred by the procedure itself."

In terms of the risk of stroke, the rate of incident stroke was 17.9 per 1,000 person-years among patients who were not ablated, but 13.1 per 1,000 person-years after ablation. That difference, however, was not significant after multivariate adjustment.

The authors acknowledged some limitations of the study, including the use of information on outcomes and potential confounders from hospital discharge coding data, which leaves open the possibility of residual confounding. In addition, the diagnosis of atrial flutter was not validated, and there was no information on ambulatory clinic visits, the use of anticoagulants and anti-arrhythmics, or flutter mechanisms.

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